I m a g i n g o f Ca rd i a c Tr a u m a

Yuhao Wu, MDa,b, Sadia R. Qamar, MBBSb, Nicolas Murray, MD, FRCPCb,
Savvas Nicolaou, MD, FRCPCb,*

KEYWORDS
 Multidetector computed tomography (MDCT)  Cardiac trauma  Pericardial/myocardial injury
 Coronary artery injury  Ascending aortic injury  Pulmonary trunk injury
 Emergency and trauma radiology

KEY POINTS
 Cardiac trauma can present in up to 76% of patients following trauma to the chest and is associated
with high mortality rates. Early diagnosis and treatment are essential to reduce deaths from cardiac
trauma.
 Multidetector computed tomography is considered the gold-standard diagnostic imaging in diag-
nosing and characterizing cardiac trauma, and should be used in all patients presenting with
abnormal electrocardiogram or Troponin I levels following chest trauma.
 The spectrum of cardiac injuries ranges from pericardial contusion to coronary artery injuries. It is
imperative for emergency and trauma radiologists to become familiar with the different injury pat-
terns of cardiac trauma.

INTRODUCTION of diagnostic imaging. We also showcase the

spectrum of pathologic imaging findings, with a
Cardiac trauma, which can present in up to 76% of focus on the use of multidetector computed to-
patients following chest trauma, is the second mography (MDCT), which has become the gold
most common cause of death in trauma after cen- standard for imaging cardiac trauma.
tral nervous system injuries.1 There are approxi-
mately 900,000 reported cases of cardiac trauma
ETIOLOGY AND PATHOPHYSIOLOGY OF
in the United States every year.1 The most com-
CARDIAC TRAUMA
mon cause of cardiac trauma is motor vehicle ac-
cidents (83%), followed by crush injuries (5.7%) Cardiac trauma can be broadly categorized into
and bicycle accidents (2.9%).2 Because traumatic blunt and penetrating cardiac trauma. Blunt
cardiac injuries often have high mortality rates, it is trauma to the chest results in the compression of
essential to have a high degree of suspicion for the heart between the sternum and the posterior
cardiac injuries in all patients presenting after spine in compression injuries, or anterior transla-
trauma to the chest. Diagnostic imaging plays a tion of the heart against the sternum in decelera-
critical role in the diagnosis and evaluation of car- tion injuries.3,4 In most cases, this result in
diac trauma so that early intervention can be initi- pericardial and myocardial contusion. Blunt in-
ated to reduce the mortality of these patients. juries with greater impact may lead to damage to
In this review article, we present the clinical the cardiac free wall, interventricular septum, the
features of cardiac trauma and discuss the role tensor apparatus, and cusps of the cardiac valves,
radiologic.theclinics.com

Disclosure Statement: The University of British Columbia Master Research Agreement with Siemens AG. How-
ever, there was no commercial funding received for this study.
a
Faculty of Medicine, University of British Columbia, 317 - 2194 Health Sciences Mall, Vancouver V6T 1Z3,
Canada; b Emergency and Trauma Radiology, Vancouver General Hospital, 950 West 10th Avenue, Vancouver
V5Z 1M9, Canada
* Corresponding author. Emergency and Trauma Radiology, Vancouver General Hospital, 950 West 10th
Avenue, Vancouver, British Columbia V5Z 1M9, Canada.
E-mail address: [email protected]

Radiol Clin N Am 57 (2019) 795–808

https://doi.org/10.1016/j.rcl.2019.02.006
0033-8389/19/Ó 2019 Elsevier Inc. All rights reserved.
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796 Wu et al

as well as the coronary arteries.4 Because of its Radiography

anterior position, the right ventricle is the most
Chest radiograph is often the initial imaging modal-
susceptible cardiac chamber in pericardial and
ity obtained at most North American emergency
myocardial contusions. However, the mitral and
departments and trauma centers following acute
aortic valves are more commonly injured than
chest trauma. Signs suggestive of cardiac trauma
the tricuspid and pulmonic valves due to the rela-
include skeletal fractures (sternal, clavicular, or rib
tively higher mural pressures in the left heart
fractures), hemothorax (shown in Fig. 1), pericardial
chambers.4
fluid, pneumopericardium, and widened medias-
Penetrating cardiac trauma includes stab
tinum. However, chest radiograph has a low sensi-
wounds, which commonly result in ventricular
tivity and specificity for cardiac injuries because of
involvement, and projectile injuries, which often
its inability to delineate overlying anatomic struc-
results in hemodynamic instability.3 It is a highly
tures and patients’ poor inspiratory effort in the
fatal pattern of injury, with previously reported
setting of severe chest pain or decreased con-
mortality of up to 94% in patients before reaching
sciousness. For this reason, cross-sectional imag-
the hospital.5 Recent advances in prehospital
ing is required for assessing the anatomic and
care and rapid transportation have significantly
hemodynamic details of the heart.10
reduced prehospital mortality.4 Nevertheless, the
mortality of penetrating trauma remains high, Echocardiogram
with gunshot wounds being more fatal than stab
wounds.6 Before the advent of multidetector computed to-
mography (MDCT), echocardiogram was widely
used as the cross-sectional imaging modality for
CLINICAL MANIFESTATIONS
assessing for cardiac trauma.11 The most common
The signs and symptoms of cardiac trauma are findings include regional wall hypokinesis/akinesis,
often nonspecific, and clinical presentation may right ventricular dilation, pericardial effusion, and
range from being asymptomatic to being in cardio- aortic injuries.9 It also can detect associated injuries
genic shock. Chest pain in the presence of sternal, such as ventricular septal rupture and valvular in-
clavicular, or rib injuries increases the suspicion for juries, as well as complications including develop-
cardiac trauma.1 Other commonly associated ment of intracardiac thrombi.4 It remains as the
injuries include pneumothorax (which occurs in imaging modality of choice for diagnosis of
39% of the patients), hemothorax (31%), and cardiac tamponade, which manifests as abnormal
lung contusions (13%).4 On physical examination, ventricular dimension changes during inspiration,
bruising is seen in approximately 30% of the pa-
tients, and new murmurs or pericardial rubs may
indicate intrinsic cardiac involvement.1
According to the Eastern Association for
the Surgery of Trauma guidelines, all patients
with suspected blunt cardiac trauma should
receive an electrocardiogram (ECG) and Troponin
I level. Troponin I, instead of creatine kinase–mus-
cle/blood (CK-MB), should be used because CK-
MB is neither sensitive nor specific for cardiac
injury.7 Cardiac injury can be ruled out only if pa-
tients have both normal ECG and Troponin I
levels.8 The most common abnormal findings on
ECG are ST segment changes 1 mm (seen on
41% of the abnormal ECGs), T-wave inversions
(31%), and right bundle branch block (15%).9
Fig. 1. A 17-year-old man presenting with multiple stab
wounds following an altercation. On clinical assess-
ROLE OF DIAGNOSTIC IMAGING IN CARDIAC ment, there was a large laceration (3 cm) just below
TRAUMA and to the left of the nipple. He had decreased air en-
try. Chest radiograph shows complete opacification of
Medical imaging plays a crucial role in the diag- the left hemithorax (red arrow) with deviation of the
nosis and characterization of cardiac trauma in pa- mediastinal structures to the right (green arrows). He
tients with abnormal ECG and/or Troponin I levels, was taken to the operating room and underwent ante-
and helps to the guide the management of these rolateral thoracotomy, which showed a left ventricular
patients. stab wound that was subsequently repaired.

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 Imaging of Cardiac Trauma 797

ventricular diastolic collapse, right atrial compres- test for all thoracic trauma and states that it should
sion, dilated inferior vena cava, and swinging heart be used in patients presenting with high-impact
within the pericardium.12,13 Fig. 2 demonstrates an trauma, abnormal chest radiograph findings,
example of CT and trans-thoracic echocardiogram altered mental status, distracting injuries, or sus-
that show features of cardiac tamponade. pected thoracic injuries. CT angiography (CTA),
However, echocardiogram has several limita- in combination with chest radiography, should
tions. Trans-thoracic echocardiogram (TTE) can be routinely used in suspected aortic injuries,
produce suboptimal images in patients with obesity, given its high sensitivity and noninvasive nature
subcutaneous emphysema, mechanical ventilation, (compared with pulmonary aortography).10 In
or chest tube insertion.14 For this reason, trans- addition, the development of ECG-gated cardiac
esophageal echocardiogram (TEE) is preferred MDCT has allowed the heart to be captured during
over TTE because of its higher diagnostic accuracy, diastole so that high-resolution images of the
but it is semi-invasive and may be contraindicated in heart, great vessels, and coronary arteries can
patients with hypotension, cervical spine trauma, be generated in a noninvasive fashion with minimal
or tracheal and esophageal structural abnormal- motion artifacts.13,15
ities.13 In addition, TEE cannot delineate the distal At the authors’ institution (Vancouver Gen-
ascending aorta and proximal descending aorta eral Hospital, Vancouver, Canada), prospective
due to obscuration by the airways.14 systolic-triggered ECG synchronized cardiac-
gated coronary CTA is performed with second
Computed Tomography generation 128-slice dual-source CT scanners.
The American College of Radiology recommends Table 1 shows the MDCT protocol and Fig. 3
MDCT as the gold-standard diagnostic imaging describes the clinical algorithm for patients

Fig. 2. A 33-year-old gentleman post polytrauma from a high-speed motor vehicle accident. He became tachycar-
diac and hypotensive on presentation. Over the course of the few minutes, he then proceeded to become
bradycardiac and eventually progressed to pulseless electrical activity. He was resuscitated with 30 minutes of car-
diopulmonary resuscitation. Contrast-enhanced CT (A) shows that there is a large pericardial effusion (red arrow)
with mass effect on the contour of the heart and narrowing of the right atrium (orange arrow). The follow-up
echocardiogram confirmed the presence of a large pericardial effusion (red arrow, B) with right atrial collapse
(red arrow, C), and diastolic right ventricular collapse (red arrow, D). This is indicative of pericardial tamponade.
He received aggressive fluid resuscitation and emergent pericardial drainage.

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798 Wu et al

Table 1
Multidetector computed tomography protocol for imaging traumatic cardiac injuries at Vancouver
General Hospital

Technique Prospective ECG-Gated Cardiac CT

Tube potential 100 kV for BMI <30
120 kV for BMI >30
Tube current 300–500 mA with ECG tube current modulation
Scan direction Cranial to caudal
Scan volume Heart to diaphragm (14–16 cm)
Size 0.5–0.6 mm reconstruction with 40% overlap,
512  512 matrix, FOV 25 cm
Detector collimation 128  0.6 mm
Cardiac phase reconstruction Relative triggering 30%–40% of RR interval, or Absolute
triggering 250 ms after R wave
Contrast bolus tracking An automated bolus-tracking algorithm is used to monitor the
attenuation within the ascending aorta; CT scanning is
automatically triggered when vessel enhancement reaches
100 Hounsfield units after contrast injection
IV contrast injection 50–80 mL Optiray contrast, followed by 50 mL 30% contrast/70%
saline mixture, and finally 30 mL of saline
IV contrast injection rate 5 mL/s
Heart rate Baseline
Beta-blocker May be utilized
Nitroglycerine May be utilized
Abbreviations: BMI, body mass index; CT, computed tomography; ECG, electrocardiogram; FOV, field of view; IV,
intravenous.
Dose-reduction can be achieved by (1) use of prospective ECG-gated technique with narrow window acquisition, ECG
tube current modulation and limited pulse windows; (2) utilization of BMI-based tube voltage reduction; (3) automated
kV reduction tool based on tomogram attenuation profile; (4) adaptive collimation limiting helical over spiral scanning;
(5) deploying iterative reconstructive techniques to reduce noise and ultimately reduce dose.
The quality of the cardiac CT can be optimized by achieving (1) heart rate <65 beats per minute by administering beta-
blocker (metoprolol 5–20 mg IV or 50–100 mg orally) 1 hour before the CT; lowering the heart rate widens diastole and
decreases beat to beat variability; (2) coronary arterial dilatation for optimal visualization can be achieved by adminis-
tering 0.4 to 0.8 mg SL nitroglycerine 5 minutes before contrast injection; (3) reconstruction algorithms to reduce
beam-hardening artifacts due to iodine mimicking ischemia; (4) edge enhancing reconstruction algorithms usage to
reduce noise due to extensive coronary calcifications or coronary stents.

presenting with suspected cardiac trauma at our MR Imaging

institution.
MR Imaging is not indicated in the setting of acute
Recent advances in dual-energy CT (DECT),
cardiac trauma because of its long acquisition
which uses 2 distinct energy levels to differentiate
time, but may be used to detect posttraumatic
materials that have similar attenuation values on
complications. Delayed enhancement MR Imaging,
conventional CT, may be valuable in detecting
which involves the injection of gadolinium agents
blunt cardiac trauma. DECT can be used to
followed by T1-weighted pulse sequence 10 to
generate perfusion mapping of the heart, as
30 minutes later, can demonstrate areas of post-
shown in Fig. 4, by quantifying the amount of
traumatic myocardial infarction (MI) and distinguish
iodine based on the attenuation characteristics of
between viable and nonviable myocardium.18
iodine when it is penetrated by 2 X-ray spectra at
different energy levels. Based on this principle,
iodine maps can be generated to assess for the SPECTRUM OF FINDINGS IN CARDIAC
luminal patency of coronary arteries and myocar- TRAUMA
dial function and perfusion at greater accuracy Pericardial Contusion/Rupture/Cardiac
than single-energy CT.16,17 Although not routinely Luxation
used in clinical practice, DECT has great potential The pericardial space lies between the visceral
in the future of cardiac trauma imaging. and parietal layers of the pericardium and may

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 Imaging of Cardiac Trauma 799

Fig. 3. The clinical algorithm for management of blunt cardiac and thoracic trauma at Vancouver General Hos-
pital. CXR, chest radiograph. (Courtesy of Vancouver General Hospital, Vancouver, British Columbia, Canada;
with permission.)

normally contain up to 50 mL of serous fluid that luxation and herniation can manifest in the
facilitates movement of the heart within the peri- displacement of the cardiac silhouette, an unusu-
cardium. Pericardial injuries range from small peri- ally shaped cardiac contour, as well as the pres-
cardial contusions (shown in Fig. 5) to large ence of colonic contents within the pericardium.20
contusions that result in pericardial tamponade CT provides higher spatial resolution, and
(shown in Fig. 6) by forming clots to seal the can help differentiate pneumopericardium from
fibrous pericardium and prevent hemorrhagic pneumomediastinum and pneumothorax. Focal
extravasation into the thoracic cavity. Pericardial pericardial defect is a direct indication of pericar-
tears, however, can extend across the entire peri- dial injury and can be seen as dimpling or
cardium and result in pericardial rupture (shown in discontinuity within the pericardium. Cardiac
Fig. 7). They account for 0.5% of all patients with herniation manifests in altered cardiac axis,
blunt trauma, but is a highly fatal finding, with mor- presence of air within the empty pericardium
tality rates of 25%.19 (“empty pericardial sac sign”), and altered car-
The most lethal complication of pericardial diac contour (“collar sign”). In contrast to radio-
injury is cardiac luxation (shown in Fig. 8), which graphs, CT provides excellent resolution of
is associated with right-sided pericardial tears. pericardial effusions. The combination of hemor-
It occurs when the heart becomes dislocated rhagic fluid within the pericardium, distended
into the right hemithorax and torsed along central veins (inferior vena cava, superior vena
the axis made by the inferior vena cava and cava, hepatic and renal veins), and displaced
the great vessels. This can result in arrhyth- cardiac chamber contour are all suggestive of
mias and hypotension causing hemodynamic cardiac tamponade.20
collapse. Tears along the diaphragmatic surface
of the pericardium may result in either cardiac
Myocardial/Ventricular Contusion/Rupture
herniation into the abdomen or the herniation
of abdominal contents into the pericardium Myocardial contusion occurs after the myocar-
(shown in Fig. 9).20 dium impacts against the sternum or the verte-
On chest radiograph, the presence of air within brae, or from shearing forces within the thorax.
the pericardium (ie, pneumopericardium) is sug- It occurs in 10% to 75% of all blunt cardiac
gestive of underlying pericardial injury. Cardiac traumas and is associated with deceleration

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800 Wu et al

Fig. 4. Conventional CT (A) and DECT (B) showing decreased iodine uptake in the septal wall suggesting
decreased perfusion to the area (red arrows). Conventional CT (C) and DECT (D) in another patient shows a perfu-
sion defect in the left ventricular free wall (blue and red arrows, respectively).

injuries where the body is moving at more than retrosternal location. Although MDCT may be
20 miles per hour.13,21 There is a large variance nonspecific for myocardial contusion, it is more
in reported incidence because definitive diagnosis useful for detecting associated mediastinal, pul-
can be made only by seeing myocardial necrosis monary, and aortic injuries.22 Fig. 10 shows a
on histologic samples, which can be attained only case of myocardial contusion with associated pul-
at the time of autopsy.21 On histology, there are monary injuries.
patchy areas of necrosis and hemorrhage, which Myocardial rupture is a rare, but often-fatal
eventually heal by myocardial fibrosis and scar- injury with a reported incidence of 0.16% to 2%
ring. In contrast to MI, in which there is gradual among all trauma patients.23 It can result from
transition between infarcted tissue and normal tis- direct compression of the heart and increased
sue on histology, myocardial contusion results in intrathoracic pressure, or may be a delayed
a distinct boundary between normal and con- complication of myocardial contusion.24 The
tused tissue.21 disruption and rupture of myocardium leads to
The right ventricle is particularly susceptible to pericardial effusion and tamponade, and also
myocardial contusion because of its anterior and can cause conduction abnormalities and result in

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 Imaging of Cardiac Trauma 801

Fig. 5. A 61-year-old woman brought to hospital after polytrauma following motor vehicle collision. (A) A CT
angiogram of the chest showed a comminuted fracture of the sternal manubrium (red arrow) with associated
mediastinal hematoma (green arrow). There is also active bleeding from a branch of the right internal mammary
artery, manifesting in breast hematoma (orange arrow). (B, C) The mediastinal hematoma (red arrows) extends to
the origins of the aorta and the pulmonary trunk. This pattern of injury is suspicious for cardiac contusion.

arrhythmias. Early diagnosis is crucial for guiding Traumatic Septal Defect

prompt surgical management of myocardial
Ventricular septal defects (VSDs) are the most
rupture. MDCT may show focal myocardial disrup-
common type of traumatic septal defects, with
tion/discontinuity, communication between car-
a reported incidence between 1% and 5%
diac chambers and the pericardial space, or
following cardiac trauma.26 Early VSDs occur
active contrast extravasation into the surrounding
within 48 hours from the initial trauma and result
space.25 This is shown in Fig. 11.
either from mechanical compression of the heart

Fig. 6. MDCT showing signs of cardiac

tamponade, which includes (A) inver-
sion of the right atrial wall (dashed
blue curve), and (B) distention of the
superior vena cava (blue arrow), both
of which are signs of increased intra-
cardiac pressure.

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802 Wu et al

Fig. 7. A 60-year-old man who presents to the emergency department after being impaled by a spike. ECG-gated
arterial-phase CT with cardiac reformats was performed. (A) There is a moderate-sized hemorrhagic pericardial
effusion (red arrow) (average attenuation 5 66 Hounsfield units). (B) There is also a small volume of blood
(red arrow) lying outside the pericardial surface in keep with penetrating pericardial injury and pericardial
tear. (C) In the lung window, there is also an associated left lower lobe laceration (green arrow) with
moderate-sized left hemothorax (red arrow, average attenuation 5 72 Hounsfield units). An emergent sternot-
omy was performed with evacuation of hemopericardium and hemothorax. The pericardial tear was repaired,
and the patient recovered well with no complications.

or from penetrating injuries. The ventricles are and combined ASDs and VSDs are less com-
most vulnerable to compression during late dias- mon, although they have been reported in case
tole after the atrial kick, when the they are filled studies.28,29
with blood and all the valves are closed. Late
VSDs occur as delayed complications from in-
Valve Injuries
flammatory response, which leads to disruption
of microvascular flow, causing liquefactive infarc- Valve injuries after cardiac trauma are rarely re-
tion and septal rupture. Early VSDs are often ported in the literature. Aortic and mitral valves
larger and more severe septal defects that require are the most commonly involved valves because
emergent surgery and are associated with higher of the higher intramural pressure in the left heart.
mortality. By contrast, late VSD rarely requires They are injured when there is increased intra-
emergent surgery and has more favorable prog- cardiac pressure across a closed competent
noses.27 Traumatic atrial septal defects (ASDs) valve. The aortic valve is most vulnerable during

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 Imaging of Cardiac Trauma 803

Fig. 8. A 59-year-old man involved in motor vehicle accident after rolling over while traveling at 100 km/h. (A)
Chest radiograph shows a left-deviated cardiac shadow with pneumopericardium (red arrow). (B) ECG-gated car-
diac CT performed showed that the cardiac apex is posterolaterally displaced to the left. (C) There is dimpling and
indentation along the right atrioventricular wall with herniation of pericardial fat (red arrow). These findings are
suspicious for pericardial rupture with cardiac luxation. This patient subsequently underwent bovine patch repair
of the pericardial rupture.

early diastole when a traumatic force can aortic valve cusps (most commonly the noncoro-
generate high pressure gradients across the nary cusp). The mitral valve is most easily injured
aortic valve, resulting in the tear of one of the during late diastole and early systole when the

Fig. 9. An 84-year-old gentleman who

was a restrained driver in a motor
vehicle crash in which he was T-boned
from the driver’s side. Axial (A) and
coronal (B) reformats of contrast-
enhanced CT of the chest, which was
performed as part of the whole-body
CT, showed that the colon and omental
fat (red arrows) extends superiorly
from the abdomen into the pericardial
sac adjacent to the heart, causing sig-
nificant mass effect on the right heart.
This is concerning for traumatic
rupture of the central tendon of the
diaphragm. He proceeded to the operating room, where the transverse colon and omentum was pulled down
from the chest and the diaphragmatic hernia was repaired.

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804 Wu et al

Fig. 10. A 29-year-old man presenting with thoracoabdominal gunshot wound and hemorrhagic shock. ECG-
gated spiral CT coronary angiogram was performed with functional imaging. (A) There was a bullet fragment
(red arrow) adjacent to the left ventricular side wall at the mid-cardiac level outside the myocardium. On func-
tional imaging (not shown), there is marked hypokinesis at this level consistent with myocardial contusion. (B)
There is also small residual left pneumothorax with extensive pulmonary contusions (red arrow), hemothorax
(green arrow), and pneumatocele formation (orange arrow) suggestive of pulmonary laceration.

inciting force impacts on the fully loaded traumatic MI is generally favorable (with a mortality
ventricle and stretches the mitral apparatus. rate of 6.5%), as most patients are younger than
The most common mitral valve injury is the 45 and have only single-vessel involvement.
rupture of papillary muscles, followed by chor- Compared with traumatic MI, coronary artery
dae tendineae and leaflet injury.30 rupture results from higher-energy traumatic
forces and can often have fatal consequences,
as it leads to sudden development of hemoperi-
Coronary Artery Injuries
cardium and cardiac tamponade. It can occur
Coronary artery injuries account for approximately from laceration by an adjacent rib, from shearing
2% of all blunt cardiac trauma and range from forces during cranio-caudal deceleration, or from
intimal tears to complete coronary artery rupture. chest compression during held inspiration (ie,
MI can result from coronary artery intimal tears Compression-Valsalva injury), which leads to sud-
or vasospasm, disruption of atherosclerotic pla- den increases in the intramural pressure within the
ques, and epicardial hematoma.31 The left anterior coronary arteries. Coronary artery rupture tends to
descending (LAD) artery is the most commonly occur in elderly patients with underlying athero-
injured artery due to its anterior location in the sclerosis, as the disease remodels the coronary
heart. In a literature review of 77 patients with MI vessels into rigid tubes that are more prone to
following blunt cardiac trauma, Christensen and rupture. The accumulation of blood in the pericar-
colleagues32 found that the LAD artery injury dium leads to the development of cardiac tampo-
occurred in 71% of patients, followed by the right nade, resulting in hemodynamic shock. Despite its
coronary artery (19.0%), the left main coronary ar- grim prognosis, Abu-Hmeidan and colleagues31
tery (6.4%), and the left circumflex artery (3.2%). found that there is often a sufficient time-window
Fig. 12 shows a case of traumatic occlusion of (ranging from 2 to 56 hours) between initial injury
the left circumflex artery. The prognosis of to death, which provides adequate time for

Fig. 11. A 49-year-old man who pre-

sented to the hospital after suffering
3 stab wounds to the chest. (A) On
arterial-phase CT chest, there are
anterior chest wall stab tracts (red ar-
rows) that pass the entire chest
wall to the pleural space. There is
a moderate-volume hemopericardium
(green arrow) with an internal air-
fluid level (orange arrow). This was sus-
picious for penetrating injury of the
right ventricular myocardium. (B) He
was taken to the operating room, where it was found that there was a full-thickness laceration of the right
atrium. He subsequently underwent repair of the right atrium.

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 Imaging of Cardiac Trauma 805

Fig. 12. A 34-year old man who suffered

blunt chest trauma after falling from a
snowboard. He had persistent chest pain
refractory to morphine, and his troponin
was elevated at 1.35. ECG-gated CT (A)
and post-processed 3-dimensional model
of the heart (B) show the left circumflex
artery abrupt cutoff (red arrows), in keep-
ing with traumatic occlusion. He was
treated with aspiration thrombectomy
and drug-eluting stent placed in the left
circumflex artery. He was discharged
with dual-antiplatelet therapy for 1 year
and aspirin for life.

patients to undergo appropriate operative interventions with either open repair or endovas-
management. cular graft repair. MDCT has recently replaced
Because of its noninvasive nature, rapid acquisi- conventional aortography for detecting
tion times, and high spatial and temporal resolu- ascending aortic injuries, and has a negative pre-
tion, ECG-gated MDCT is often used as the first- dictive value approaching 100%.35 Figs. 13 and
line modality for imaging of coronary tears, dissec- 14 show grade 1 and grade 2 injuries of the
tion, and thrombosis. These patients can be further ascending aorta, respectively.
assessed using coronary angiography or intracoro- Injuries to the pulmonary artery are extremely
nary ultrasound to guide proper management.33 rare in patients presenting with thoracic trauma.
In a series of 585 autopsies conducted after
blunt trauma, only 4 had injury to the main pul-
Injuries to the Great Vessels
monary artery.36 They are, however, fatal injuries
Injuries to the aortic root and ascending aorta with survival rates of less than 30%.37 Thus, it is
account for approximately 5% of all thoracic important to be vigilant for pulmonary artery in-
aorta injuries. Azizzadeh and colleagues34 cate- juries, which can occur from deceleration, fall
gorized traumatic aortic injuries into 4 grades from a height, or from imprints from the steering
based on severity: (1) grade 1: intimal tear/mini- wheel. Patients can present in various ways: (1)
mal aortic injury; (2) grade 2: intramural hema- massive hemothorax from injury to the hilar
toma; (3) grade 3: aortic pseudoaneurysms; structures; (2) contained hemorrhage leading
and (4) grade 4: free rupture. Patients with grade to aneurysm formation; (3) delayed onset of
1 injuries can be managed medically, but those large pleural effusion; and (4) pericardial tampo-
with higher-grade injuries require operative nade.38 Chest radiograph may show widened

Fig. 13. Axial (A) and Sagittal (B) reformats of ECG-gated CT images obtained following intravenous contrast
shows that there is a short flap arising in the noncoronary cusp of the aortic valve (red arrows), (approximately
16 mm distal to the aortic annulus) in the proximal ascending aorta. This was deemed to be not requiring oper-
ative intervention and the patient remained stable over the remainder course of hospitalization.

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Fig. 14. Axial (A), coronal (B), and sagittal (C) images of a 65-year-old woman who received intravenous contrast-
enhanced trauma protocol of the chest, abdomen, and pelvis. There is a crescent-shaped intramural hematoma
(red arrows) arising from the aortic root along the ascending aorta, as well as an area of contrast extravasation
(green arrow) at the junction of the ascending and proximal transverse aorta. In addition, there is a component
of hemopericardium (orange arrow), and mixing of blood within the aorta (purple arrow).

mediastinum, first rib fracture, scapular fracture, pulmonary artery and allows for surgical planning
or hemopneumothorax.37 MDCT may demon- before thoracotomy. Fig. 15 shows an example
strate active contrast extravasation from the of pulmonary artery injury.

Fig. 15. Axial (A) and coronal (B) im-

ages of pulmonary artery injury
following motor vehicle accident.
There is soft tissue thickening repre-
senting contained hematoma (red ar-
rows) surrounding the pulmonary
trunk with irregular contrast pooling
(green arrows) that appears to be
continuous with the main pulmonary
trunk, suggestive of pulmonary artery
injury.

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 Imaging of Cardiac Trauma 807

SUMMARY 11. Vignon P, Boncoeur MP, François B, et al. Compar-

ison of multiplane transesophageal echocardiogra-
Traumatic cardiac trauma is the second most phy and contrast-enhanced helical CT in the
common cause of trauma-related deaths. Clini- diagnosis of blunt traumatic cardiovascular in-
cians should have a high index suspicion for car- juries. Anesthesiology 2001;94(4):615–22 [discus-
diac injuries following chest trauma. Diagnostic sion: 615A].
imaging plays a crucial role in directing the early 12. Fowler NO. Cardiac tamponade. A clinical or an
diagnosis and management of cardiac trauma. In echocardiographic diagnosis? Circulation 1993;
the past few decades, MDCT has evolved to 87(5):1738–41.
become the gold-standard imaging modality 13. Co SJ, Yong-Hing CJ, Galea-Soler S, et al. Role of
because of its rapid acquisition, high resolution, imaging in penetrating and blunt traumatic injury to
and noninvasive nature. To accurately diagnose the heart. Radiographics 2011;31(4):E101–15.
and characterize the extent of cardiac injuries, ra- 14. Chirillo F, Totis O, Cavarzerani A, et al. Usefulness of
diologists need to understand the mechanism of transthoracic and transoesophageal echocardiogra-
cardiac trauma and become familiar with the com- phy in recognition and management of cardiovascu-
mon injury patterns. lar injuries after blunt chest trauma. Heart 1996;
75(3):301–6.
15. Malbranque G, Serfaty JM, Himbert D, et al.
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